What is the diagnosis and treatment for Sleep Onset Association Disorder (SOAD)?

From the Guidelines

To address Sleep Onset Association Disorder (SOAD), implement a consistent bedtime routine and gradually remove the problematic sleep associations, as this approach has been shown to improve sleep quality and quantity, and reduce insomnia-related daytime impairments 1.

Diagnosis of SOAD

The diagnosis of SOAD involves identifying the specific conditions or objects that a child relies on to fall asleep, and assessing the impact of these associations on the child's ability to self-soothe and sleep independently. This can be done through a thorough clinical evaluation, including a sleep history and observation of the child's sleep patterns.

Treatment of SOAD

The treatment of SOAD typically involves a combination of behavioral interventions, including:

• Establishing a consistent bedtime routine to signal to the child that it is time for sleep
• Gradually removing the problematic sleep associations, such as parental presence or object dependencies
• Encouraging the child to self-soothe and fall asleep independently
• Using techniques such as "gradual withdrawal" to slowly increase the distance between the child and the caregiver over several nights
• Introducing a transitional object, such as a small blanket or stuffed animal, to provide comfort without creating problematic dependencies

Evidence-Based Recommendations

The American Academy of Sleep Medicine recommends psychological and behavioral interventions, including cognitive behavioral therapy for insomnia (CBT-I) and multicomponent behavioral therapy, as the primary treatment for insomnia disorder 1. These interventions have been shown to improve sleep quality and quantity, and reduce insomnia-related daytime impairments. In the context of SOAD, these interventions can be adapted to address the specific sleep associations and behaviors that are contributing to the disorder.

Key Considerations

• Consistency is crucial in addressing SOAD, and all caregivers should follow the same approach to ensure that the child learns to self-soothe and sleep independently
• The treatment of SOAD should be tailored to the individual child's needs and circumstances, and may involve a combination of behavioral interventions and other therapies
• The goal of treatment should be to improve sleep quality and quantity, and reduce insomnia-related daytime impairments, as measured by outcomes such as the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI) 1.

From the Research

Diagnosis of Sleep Onset Association Disorder (SOAD)

• Sleep Onset Association Disorder (SOAD) is characterized by difficulty falling asleep or staying asleep due to associations between sleep onset and certain stimuli or activities 2
• Diagnosis of SOAD is based on a comprehensive sleep history and physical examination to rule out other sleep disorders or medical conditions that may be contributing to the sleep disturbance 3
• A systematic elimination of other specific sleep disorders, such as sleep apnea or restless legs syndrome, is necessary to ensure an accurate diagnosis of SOAD 2

Treatment of Sleep Onset Association Disorder (SOAD)

• Treatment of SOAD typically involves a combination of non-pharmacological and pharmacological approaches 2, 4
• Non-pharmacological strategies include:
  • Parental education to promote sleep development 2
  • Establishing bedtime rituals adapted to the child's age and particularities 2
  • Behavioral strategies such as bedtime fading, gradual extinction, and positive reinforcement of adapted behaviors 2
• Pharmacological treatment may involve the use of melatonin, which has been shown to be effective in improving sleep onset and duration in children with autism spectrum disorders (ASD) 2, 4, 5, 6
• Melatonin treatment should be individualized and monitored closely to minimize potential side effects and ensure optimal efficacy 4, 5, 6